Noma-like lesion in a patient with acute promyelocytic leukemia

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Rev Bras Hematol Hemoter. 2011;33(4):315-22 321
Noma-like lesion in a patient with acute promyelocytic leukemia
1
Department of Stomatology,
Faculdade de Odontologia de
Bauru, Universidade de São Paulo
– USP, Bauru, SP, Brazil
2
Department of Oncology and
Hematology, Faculdade de
Ciências Médicas, Santa Casa de
São Paulo – FCMSCSP, São Paulo,
SP, Brazil
Paulo Sérgio da Silva Santos1
Nathalia Bigelli Del Neri1
Carlos Sérgio Chiattone2
Conflict-of-interest disclosure:
The authors declare no competing
financial interest
Submitted: 4/15/2011
Accepted: 4/28/2011
Corresponding author:
Paulo Sérgio da Silva Santos
Department of Stomatology, Faculdade de
Odontologia, Universidade de São Paulo –
USP
Al. Dr. Octavio Pinheiro Brisolla, 9-75
17012-901 – Bauru, SP, Brazil
Phone: 55 14 3235-8000
paulosss@fob.usp.br
www.rbhh.org or www.scielo.br/rbhh
DOI: 10.5581/1516-8484.20110087
The term noma is used to describe a
spreading, invasive gangrene with edema of the
face which starts as an ulcer of the mucous
membrane and extends from in outwardly,
rapidly perforating and destroying soft tissues
and bone and almost always rapidly fatal.(1,2)
The disease occurs mainly in children from
deprived areas with low levels of hygiene. Cases
of children are common and occur mainly in
under-developed countries; adult cases are rare
and are reported predominantly in developed
countries. However, some adult cases can be
attributed to malnutrition and to a predisposition
to infectious disease.
Leukemia is increasingly being recognized
as an associated factor.(2) Patients with leukemia
are at a high risk of developing nomas during
chemotherapy, as this can induce agranulo-
cytosis.(3) Regardless of the type of initial lesions,
gangrene always develops rapidly, but remains
well defined.(3) Most patients do not consult their
doctor until the disease is at an advanced stage,
its onset and progression remains a mystery.(1)
The prognosis for childhood noma has improved
dramatically since the discovery of antibiotics,
prior to which there was only a 15% survival rate
whereas now only 15% succumb to it.(2) Prompt
and appropriate antibiotic therapy can ensure
the patient´s survival with an aesthetically
acceptable outcome.(3)
A 17-year-old Caucasian male, who had
had throat pain and odynophagia for one week,
was submitted for blood tests (Hemoglobin: 7.0
g/dL; Hematocrit: 21%; WBC: 33 x 109 cells/L
and platelets: 38 x 109 cells/L). Acute pro-
myelocytic leukemia (M3) was diagnosed and
the patient was treated with daunorubicin plus
Figure 1 - Extensive necrotic lesion in the m. palatoglossus, soft palate, uvula and right tonsil with foul
odor
vesanoid. A physical examination demonstrated
an extensive necrotic lesion in the M.
palatoglossus, soft palate, uvula and right tonsil,
accompanied by an unpleasant odor (Figure 1).
Samples were collected for biopsy and culture.
The histopathologic findings showed non-
specific chronic diffuse inflammation infiltrated
by necrotic areas and numerous bacteria. The
culture identified Enterococcus spp ,
Staphylococcus aureus and Candida SP. In
accordance with the histological and
bacteriological findings it was concluded that
this was a noma-like lesion. The patient then
received antibiotic therapy using ceftazidime,
amicacin, vancomycin, fluconazole and penicillin
G. The patient developed pneumonia and sepsis
and was treated in the intensive care unit. Total
recovery albeit with extensive loss of soft palate
tissue was attained in 45 days.
Cancrum oris (noma) occurs predominantly
among deprived and poorly nourished children in
developing countries, who have poor oral hygiene.
It is often associated with infections such as
measles and rubella.(1,3) In 90% of cases, nomas
develop before the age of 10 years old.(4) Other
commonly associated diseases include: typhoid
fever, whooping cough, typhus, syphilis,
tuberculosis and leukemia in descending order
of frequency.(1,3,4) To the best of our knowledge,
there are only five cases reported concerning
nomas or noma-like lesions in patients with
oncohematological malignancies in PubMED
(Table 1).
It is difficult to pinpoint any specific
triggering agent in the complex microbiota of a
noma.(1) Streptococcus, Fusobacterium and
Bacterioides have been associated with cancrum
Letter to Editor
322 Rev Bras Hematol Hemoter. 2011;33(4):315-22
oris.(3) This patient´s lesion was diagnosed as a noma-like lesion
because of the similarity of its clinical features: rapid progression to
gangrenous necrosis of the hard and soft palate, uvula and right
tonsil, leading to severe mutilation, as seen in noma lesions but of a
different etiopathogenesis (Enterococcus spp, Staphylococcus
aureus and Candida SP infection).(7)
The differential diagnoses are: mucocutaneous leishmaniasis;
lupus erythematosus; leprosy; agranulocytic ulcerations; physical
trauma (including burns); syphilis; oral cancer and yaws.(1) Infections
of the oral cavity can spread to other parts of the body.(1) The
prognosis for nomas is largely dependent upon early and accurate
diagnosis and treatment.
References
1. Auluck A, Pai KM. Noma: life cycle of a devastating sore - case
report and literature review. J Can Dent Assoc. 2005;71(10):757.
2. Bendl BJ, Padmos A, Harder EJ, McArthur PD. Noma: report of
three adult cases. Aust J Derm. 1983;24(3):115-21.
3. Brady-West DC, Richards L, Thame J, Moosdeen F, Nicholson A.
Cancrum oris (Noma) in a patient with acute lymphoblastic
leukaemia. West Indian Med J. 1998;47(1):33-4.
4. Akar N. Noma. Lancet. 2006;368(9540):989. Comment in: Lancet.
2006;368(9530):147-56.
5. Weinstein RA, Choukas NC, Wood WS. Cancrum oris-like associated
with acute myelogenous leukemia. Oral Surg Oral Med Oral Pathol.
1974;38(1):10-4.
6. Limongelli WA, Clark MS, Williams AC. Nomalike lesion in a
patient with chronic lymphocytic leukemia. Review of the
literature and report of a case. Oral Surg Oral Med Oral Pathol.
1976;41(1):40-51.
7. Erbagci Z. Noma-like gangrenous cheilitis in a child with cyclic
neutropenia associated with myeloperoxidase deficiency. Pediatr
Dermatol. 2003;20(6):519-23.
Letter to Editor
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